Whatever went wrong with Virginia's gun background check
system or the Navy security protocols or the neurons in Aaron
Alexis's delusional and angry brain, none of that matters now to
the 12 souls who were tragically killed on Sept. 16, 2013. They are
gone. They don't care about balancing gun rights and public safety.
They don't care about Thanksgiving this November. They won't
be there.

Heartbroken family members of the victims of the Navy Yard shooting
do care, and so should the rest of us. But we should also care about the
85 other people who were shot to death the same day in the United
States--and the 85 who are shot every day, many by their own
hand--according to Centers for Disease Control and Prevention data.

Why is this happening?

The root causes of our national gun violence epidemic are many and
complex, but it seems easier these days to blame one thing: mental
illness. After all, what person in their right mind massacres strangers?

According to a national poll conducted earlier this year by Johns
Hopkins Bloomberg School of Public Health, a majority of adults in the
United States support increasing government spending on mental health
screening and treatment as a strategy to reduce gun violence (N. Engl.
J. Med. 2013;368:1077-81); National Rifle Association members and
gun-control advocates agree on very little, but there is that.

Of course we need better mental health care in America. The public
mental health system is a disaster in most states--fragmented,
ineffective, overburdened, and underfunded. An estimated 3.5 million
people with serious mental illnesses are going without treatment every
year. But they are not the nub of the violence problem.

Mental disorders are responsible for about 4%-5% of violent
incidents in the United States. If we cured schizophrenia, bipolar
disorder, and major depression overnight, 95% of violent acts toward
others would still occur. A person with mental illness is far more
likely to be a victim of violence rather than a perpetrator.

When we include suicide as part of the gun violence epidemic,
mental illness is a much stronger causal factor. Suicides account for
61% of all firearm fatalities in the United States--19,393 of the 31,672
gun deaths reported by the CDC in 2010. Suicide is the third-leading
cause of death in Americans aged 15-24 years, perhaps not coincidentally
the age group when young people go off to college, join the military,
and experience a first episode of major mental illness if it's
bound to happen.

More than half of suicides involve guns, and most victims had
identified mental health problems and a history of some treatment.
"How did they get a gun?" is an important question to answer.
"Where was the treatment, and why did it fail?" might be even
more important.

Suicide attempts with a gun almost invariably succeed, because they
are almost always aimed at the brain at dose range, and there is seldom
anyone around to call 911. In contrast, most victims of other-directed
firearm violence survive. They are often disadvantaged young people left
to struggle with lifelong disabilities in places where hope runs thin.
The burden of their care and lost productivity are a big part of the
$170 billion price tag for gun violence in America.

How about profiling mass shooters--can we thwart the next mass
shooting? Profiling multiple-casualty killers is not difficult.
Predicting them in advance is almost impossible. Most of them are young
and male. They tend to be angry and socially isolated. Some of them have
delusional beliefs. Some use illicit drugs, drink too much alcohol, play
violent video games, and are preoccupied with weapons. Should we round
up all the angry young men who fit this description? Lock them up and
treat them?

The problem with that strategy is that the description also applies
to tens of thousands of young men in America who would never perpetrate
a mass shooting in a million years.

Could the problem have something to do with unregulated guns? The
average crime rate in the United States over the past 50 years is very
similar to that of Canada, the United Kingdom, and most Western European
countries. But our homicide rate is several times higher than the
average homicide rate in those countries. We don't have an
exceptional crime problem in America. We do have an exceptional murder
problem. The reason for that, in part, is that we have approximately 310
million firearms in private hands in the United States. Lots of people
in other countries get angry and hurt each other and commit crimes, too.
But here, we do it with guns; more people die.

We have tried sensible gun control in the United States, and there
is evidence that it can work. In 1975, the District of Columbia enacted
the Firearms Control Regulations Act, which effectively banned handguns
in the district. Colin Loftin, PhD., and his colleagues published a
study in 1991 showing that the law resulted in a dramatic decline in gun
homicides and suicides; it saved an estimated 47 lives each year in the
District of Columbia during the period it remained in effect (N. Engl.
J. Med. 1991;325:1615-20).

The irony in Dr. Loftin's study is that it validated the
public safety benefit of the very law that the US. Supreme Court struck
down as unconstitutional in District of Columbia v. Heller. The
court's decision in Heller, expanded to the states in McDonald v.
Chicago, affirmed that the Second Amendment confers an individual right
to possess firearms for personal protection. Never mind the scientific
evidence for how dangerous this might be.

After Heller, we can't broadly limit legal access to guns
here, as other countries have done. We have to do something more
difficult, which is to try to keep guns out of the hands of certain
"dangerous people." But we often don't know who the
dangerous people are (until it's too late), and the people that we
might assume to be dangerous (say, because they have a mental illness)
mostly are not. Our existing federal prohibitions, inherited from the
Gun Control Act of 1968, are both overinclusive and underinclusive. As a
result, people who are dangerous can slip through the cracks, while
people who are not dangerous can be unfairly subjected to stigma.

Given that psychiatrists' predictions of violence aren't
much better than a coin toss, and we live in a country awash in
firearms, reducing gun violence in the tiny proportion of mentally ill
individuals at risk is a vexing challenge. A policy to seize guns, at
least temporarily, from people during and immediately following a
dangerous mental health crisis--a law like the ones Indiana,
Connecticut, and California already have in some form--might be a place
to start.

By itself, such a law may have only a marginal effect. But it could
make a difference in combination with other sensible measures that would
be permissible under the Second Amendment--policies such as requiring
universal background checks, beefing up enforcement and lowering
evidentiary standards for prosecuting illegal gun transfers, banning
assault weapons and high capacity ammunition magazines, and maybe
requiring personalized gun technology to ensure that a gun could be
operated only by its licensed owner.

That firearms have become a symbolic issue in a paralyzed political
debate over individual rights and government intrusion is enough to make
a public health--minded researcher or clinician, on a bad day, lose hope
for evidence-based policy. A good day will be one with more reasonable
conversation about firearms, fewer people with untreated mental illness,
and nobody dead from a gunshot in America.

We do need to improve mental health care in this country; we need
more effective treatments and better access to services for people with
serious mental illnesses. That said, people with mental illness are
really not the source of our social problem of gun violence. Mass
shooters with mental health problems get a huge amount of media
attention, but they do not represent most people treated by
psychiatrists. They're also atypical of most people who commit
violent crimes. We need to think more broadly about mental illness and
violence in society as two separate public health problems that overlap
at the moment of such tragedies.

Caption: Two police officers guard the front entrance to the
Washington Navy Yard after a government contractor went on a rampage and
killed 12 people. The U.S. homicide rate surpasses the rate found in
Canada or the United Kingdom.

Caption: DR. SWANSON

Caption: DR. SWARTZ

BY JEFFREY SWANSON, PH.D., AND MARVIN SWARTZ, M.D.

Dr. Swanson is professor of psychiatry and behavioral sciences at
Duke University Medical Center, Durham, N.C. He is principal
investigator of a multisite study on firearms laws, mental illness, and
prevention of violence, cosponsored by the National Science Foundation
and the Robert Wood Johnson Foundation's Program on Public Health
Law Research. Dr: Swartz is professor of psychiatry and behavioral
sciences and head of the division of social and community psychiatry at
Duke University Medical Center. His current research focuses on the
effectiveness of firearms laws, involuntary outpatient commitment,
psychiatric advance directives, and antipsychotic medications. Scan the
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